Nostalgia and Insanity

Thomas Nast’s Picture of a Homesick Soldier

America’s Civil War left many soldiers with lingering mental ailments that degraded their quality of life or disrupted it so violently they were considered insane. Today we would likely call these problems post-traumatic stress disorder, but in the 19th century it would have been called soldier’s heart or irritable heart.

Another syndrome that affected soldiers during the war was called nostalgia. Men (and boys) who had never traveled far from home were suddenly in a strange place away from family and friends. Many were so homesick that they fell into depression and despair, stopped responding to the people and stimuli around them, and sometimes became so lethargic and apathetic that they died.

John Clem, a 12-Year-Old Union Drummer Boy, Would Surely Have Had a Hard Time Coping With Homesickness

Nostalgia was recognized in the 1863 Manual of Instructions for Enlisting and Discharging Soldiers. The manual said: “Nostalgia is a form of mental disease which comes more frequently under the observation of the military surgeon… it belongs to the class Melancholia.”

The typical camp treatment for nostalgia was to shame soldiers for it, increase their drilling and other training, or push them into combat to stimulate them. Letting them take leave, or furlough, was also an option, but camp physicians had little use for it. Many were more concerned about the physically ill and wounded–whose symptoms could not be faked–than they were with uninjured soldiers who had symptoms that could.

It Would Have Been Impossible to Treat Nostalgia in a Civil War Hospital Like This

This cold attitude was driven more by the wartime situation than the prevailing attitude of the era. Moral treatment, with its kinder outlook and sympathetic treatment of the mentally ill still dominated treatment in asylums. Unfortunately, the Civil War demanded soldiers so relentlessly that physicians found it hard to justify releasing a relatively able-bodied soldier from the army, for any reason.

Nostalgia was a very old term for the illness it represented, and the Civil War was the last war in which Americans used it as a diagnosis.

Mental Illness and the Civil War

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Civil War Soldier Angelo Crapsey, 1861, Who Committed Suicide in 1864 After a Period of Mental Illness, courtesy Kutztown University of Pennsylvania

Societies have always observed that participating in wars/battles could affect both the soldiers and civilians caught up in the violence, and not only through physical wounds. After America’s Civil War, people called this change in veterans the “soldier’s heart” phenomenon. At the time, observers believed the negative changes were caused by actual physical changes in the heart that had occurred during war, or that the affected soldiers had longed for home so much that the fixation or focus had affected their minds.

Lunatic asylums had been available to the public for over two decades by the time the Civil War ended, but many families were ashamed to send relatives to them. When soldiers returned from the war, however, families sometimes faced overwhelming problems trying to care for them. If the soldiers were badly wounded, for example, physical care would be demanding and expensive, and mental problems in addition might make giving home-care nearly impossible. Some soldiers returned home with alcohol or morphine dependencies which could also make them difficult to nurse. And, many families–particularly in the South–were too impoverished to provide adequate care for their loved ones.

Milledgeville Lunatic Asylum, GA, Received its First Patient in 1842

Some of these issues may have driven families to place their veterans in an asylum. At the time, treatments for the insane consisted primarily of rest, occupational therapy, and adequate care for any existing physical problems. Receiving these things would have helped many patients, as would the relative peace that came from the stability and routine found in an asylum. Little besides some light labor and observance of the rules would have been expected from these patients, and many soldiers possibly welcomed the change and the chance to rest from the uncertainty and stress of the battlefield. Asylum cure rates during this period after the war could be around 30 to 40 percent–high, but possibly accurate.

Soldiers Could Be Traumatized When They Saw Friends and Comrades Die, photo courtesy Library of Congress, 1861

Though many families continued to resist asylums and could not get beyond the stigma of insanity, others who used the asylums possibly saw a benefit. At the very least, many families may have felt that under post-war circumstances, they could have provided no better care, themselves.

Medical and Mental

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Dr. Howard W. Haggard

Writing in 1929, Dr. Howard W. Haggard, an associate professor at Yale University, said: “. . . the treatment of mental disease is not so well developed as the treatment of other diseases because insanity has only recently been recognized as a medical problem.” Until shortly before that time, insanity was considered (among other theories) the result of moral failures, harmful actions on the body from outside factors like sunstroke, overwork, a terrifying experience, etc., or heredity weakness.

Dr. Haggard also noted that insanity was the only disease that went through a court of law. Though this precaution was presumably taken because the diagnosis could deprive victims of their liberty, Haggard pointed out that a diagnosis of a communicable disease like smallpox could also deprive victims of their freedom through an enforced quarantine. No one required a legal ruling on a smallpox diagnosis, so why the distinction? Haggard believed that insanity had to pass through a court of law primarily because its diagnosis was “not as positive as is the diagnosis for other diseases.”

An Example of Diagnosing Insanity Via the Legal System

Early Psychiatrists Had Little Idea What Caused Insanity

In this telling statement, Haggard pinpoints the reason we are still arguing today about the validity of diagnosing mental illness. What test is available for a particular mental illness? Whose standards need to be met for a person to be considered free of mental illness? If mental illness is a real condition, why does its definition change over time? A strong sex drive in women used to be considered a form of mental illness, for example, as was epilepsy and syphilis. What currently acceptable behavior will be considered an illness down the road, or what “mental illness” today will science discover is actually a physical illness?

Because these questions cannot be easily answered and have an enormous impact on an individual’s freedom, we as a society will doubtlessly continue the debate for many years.

Work and Money

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Clarinda State Hospital Was Impressive

Even new insane asylums–presumably built by the demands of a state’s constituents–often had money woes. For many institutions, funds were only provided every two years via legislative appropriations. This meant that they were built piecemeal, seemingly always a step or two behind the real needs of patients and their families. Clarinda State Hospital in Iowa is probably typical.

Iowa’s General Assembly passed an Act to establish the asylum in April, 1884 and the Iowa Grand Lodge of Masons laid the cornerstone in July. A central building and supervisor’s department were nearly finished by December, but it wasn’t until the 1886 session that money was appropriated to go further. The institution opened late that year and accepted its first patients: 222 males received from other asylums. As legislative sessions continued, the asylum received additional funds for building and continued to complete the design which had been planned for it. Finally, in 1897, the asylum stood as a complete entity.

Patients Working in Laundry Room at Fulton State Hospital circa 1910, courtesy Missouri Archives

As soon as patients arrived, they began working. They graded, sodded, planted, and farmed–hard work rather than the “light” therapeutic work that alienists sincerely believed helped patients occupy their time, divert their minds, and heal both mind and body. Besides the outdoor toil, patients helped a hired tailoress make all the clothing worn by patients (except for white dress shirts, hose, and hats). The asylum’s residents also made their own furniture and shoes, brooms, and mattresses under the supervision of professionals assisted by patients.

Patients Worked at Useful Tasks at Most Asylums, photo courtesy Buffalo Psychiatric Center

Though work did help patients–especially if they wanted to do it–the probability remains high that many patients were subtly coerced into labor they would not have done otherwise. For superintendents charges with controlling costs, the proximity of so much free labor was likely a temptation they didn’t always resist.

Other Ways to Help the Insane

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Wet Sheet Pack, 1902

Alienists considered light labor a welcome change of pace for patients and a great boon to their recovery (see last post) during the Civil War era. However, they also realized that every patient needed an individual plan that might include other therapeutics than labor, or no labor at all. Most specialists hoped that a calm, supportive environment would bring a patient back to health, but did recognize that sometimes more aggressive measures were needed.

If a patient showed signs of violence, there were several courses open to attendants. Restraint might be necessary, but what kind? “The worst form is where patients are held by the attendants,” said Dr. J. Paragot in his article, “General Mental Therapeutics.”

Restraints Could Be Horrifying For Patients

The next worst form of restraint was a cell, because attendants had to use force to place a patient in one, and then left him/her there in a state of frustration. In Dr. Paragot’s opinion, the best form of restraint was a leather strap around the wrists. “. . . the patient may enjoy the liberty of walking in the fields. . . . the patient may be left alone, no offered active violence overpowers him, it is but a passive resistance which annihilates his efforts.”

Moral restraint, imposed through “love, kindness, and reward” could also motivate patients to change their behavior. Hydrotherapy of various sorts–including swimming in tepid pools–could be beneficial, especially if a patient had the will to change but not the ability. Air baths (rambling about in the open air) could take the place of hydrotherapy for “the higher classes” in order to avoid any type of violence to the patient. Finally, a nutritious diet often helped patients enormously, particularly when they had physical problems as well as mental issues.

Elixer of Opium Promoted Restful Sleep and Composure and Relieved Nervous Excitement

Tonics and stimulants had their place for patients needing that kind of help, but Paragot generally urged the mildest means possible when doing anything more than counseling a patient. He recognized that hydrotherapy and various types of restraint options were often accompanied with violence toward a patient, which he found particularly negative in terms of a therapeutic outcome. If his enlightened views had prevailed, asylums might not have earned the disdain and dismay that haunt them to this day.

Ways to Treat the Insane

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Leisure Time at Southwestern Lunatic Asylum, circa 1890, courtesy Southwestern Virginia Mental Health Institute

Around the time of the Civil War, alienists were still hammering out the best ways to treat the mentally disturbed. Asylums were much more common, and a great majority of alienists felt that removal to one would benefit most patients more than home care. What they particularly stressed was an immediate change of scenery–either to an asylum or by travel–for a patient in the first stage(s) of insanity. By getting this person away from the environment that had brought on the problem, doctors could often snap the person out of the state of mind causing the insanity.

Labor of some kind was also beneficial for the physical health and mental recovery of the insane, which led most asylums to set up gardening and workshop programs for their patients. The author (Dr. J. Parigot) of an 1864 article “General Mental Therapeutics,” did stress that labor must be voluntary. “Free-will labor has the advantage that patients instinctively choose occupations in accordance with their state of health,” Pargot noted. But he also gave the following caveat: “. . . patients ought never to be converted into machines and tools for private speculation.” He was very much against using patient labor to keep down expenses so that an asylum could be self-paying or profitable.

Interior of Shoe Shop, Willard Asylum for the Insane

Unfortunately, therapeutic labor soon came to include drudge work and difficult farm and dairy tasks that most patients probably did not enjoy. As asylums took in more patients with less per capita state funding, they had to rely on patient labor to offset the costs of food and other goods.

Patients Picking Cotton at Alabama Insane Hospital

My next post will continue to discuss therapeutics during the Civil War era.

Plight of the Attendant

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Stephen Smith, State Commissioner of Lunacy in New York, courtesy Appletons Encyclopedia

Most asylum accounts deal with the hardships patients faced, but the employee side had difficulties as well. Dr. Stephen Smith, the State Commissioner of Lunacy in New York, wrote about a particularly difficult type of patient for a paper submitted to the National Conference of Charities and Corrections in 1885. In his “Care of the Filthy Cases of Insanity,” Smith explained the problems caused by this particular “class” of patients.

Filthy patients were those who constantly soiled themselves (whether by accident or design) and required a great deal of any conscientious attendant’s time. In his paper, Smith wrote: “I have seen patients in the asylums of this State who were thoroughly bathed, and had a complete change of under-clothing, and two or three times of their external clothing, eighteen times in a single day. And this occurred in spite of constant watchfulness to anticipate their wants.”

Male patients being washed by hospital orderlies. Credit: Wellcome Library, London. Wellcome Images images@wellcome.ac.uk http://wellcomeimages.org Male patients being washed by hospital orderlies, Long Grove Asylum, Epsom. In the Royal College of Psychiatrists. circa 1930? Published: - Copyrighted work available under Creative Commons by-nc 2.0 UK, see http://wellcomeimages.org/indexplus/page/Prices.html

Male patients Being Washed by Hospital Orderlies, courtesy Wellcome Library, London. Wellcome Images
images@wellcome.ac.uk

Smith encouraged asylums to place filthy patients on a toilet training and personal care program. He also recommended that sufficient staff for a “night service” be employed, their duties being to help with this training program and to ensure messes were promptly cleaned so as not to disturb other patients in the room. When these measures were adopted, Smith had seen wonderful improvements in ward cleanliness, neat and tidy patients, and a much more pleasant atmosphere. Though constant vigilance would have been burdensome, it is still easy to believe attendants would rather have watched these patients closely than clean them up after an accident.

Executive Committee of the National Conference of Charities and Correction, courtesy of the social welfare library, vcu.edu

Because many asylums cut their night staffs to provide simple monitoring rather than active care, the financial burden to provide more attendants was likely rejected by most asylums. Day attendants were also stretched thin to save money, but without these measures in place, the stress of time-consuming and unpleasant clean-ups very likely caused more than a few attendants to snap–either at the offender or a handy target.

Plight of the Sane

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Part of the Original Asylum, Previously Known as the Asylum for the Insane. The Facility Opened in 1818 as a Division of Massachusetts General Hospital

People who were tricked into an asylum by relatives or friends have given heartbreaking accounts of the experience, and Elizabeth T. Stone was no exception. After attending a family gathering on Thanksgiving, she went with her brother to what she thought was a boarding house. She was puzzled by the odd way she was treated upon arrival, the barred windows, and the regimented meals and bedtimes, but it was not until her second day that she learned she was at McLean Asylum and that her brother had had her committed there.

Stone’s despair was enormous, but she had the wit not to show her frantic emotions. She knew her protests and defensive statements would be put down to her “derangement” and that this easy label would not help her with the physicians there. Stone attributed her commitment to the asylum from the religious disagreement she had with her family, but her experience is so much more a lens on the easy commitment laws that prevailed at the time.

A Gilbert Stuart Painting of John McLean, Who Bequeathed a Fortune to the Asylum

A Sketch of the Life of Elizabeth T. Stone and of her persecutions

Stone apparently broke down within a short time and and made up her mind to commit suicide by tearing off a strip of her sheet so she could hang herself. The sheet gave way before she actually died, but the incident brought her more restriction. She continued to deteriorate mentally and lost a degree of self-control, though she was always aware of her surroundings. Stone eventually was released to one of her brothers and wrote a bitter account of her stay at McLean. Her book, A Sketch of the Life of Elizabeth T. Stone, was published in 1842.

Asylum Superintendent’s Job Included Danger

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American Journal of Insanity

Dr. John Gray (see last post) was an influential, well-known alienist, long-time editor of the American Journal of Insanity, and superintendent of the State Lunatic Asylum at Utica, NY. He was also the chief medical expert who had testified for the prosecution at the trial of Charles J. Guiteau, the assassin of President James Garfield in 1882. While sitting in his office one evening of that same year, Gray was shot through the upper jaw by Henry Remshaw in the presence of three other people (including his son, John Gray, Jr.).

Assassination of James Garfield, courtesy Smithsonian Magazine

Remshaw’s deed was thought to have been provoked by some aspect of the Guiteau’s trial, and he had apparently made several threats against Dr. Gray previous to the actual shooting. Remshaw ran outside the asylum to avoid capture, fired at his pursuers, and finally reached his home. There, he told a woman living on the lower floor that he had killed Gray, then “danced about, showed her four revolvers, a dirk, and piles of cartridges” and then told her he would give himself up.*

Inmates in Lockstep at Auburn Prison

When Remshaw did give himself up at the Mohawk Street jail, he turned over his four loaded weapons and cartridges, plus a bottle of acetic acid and opium. Remshaw raved that he was an ambassador sent from heaven to kill Gray, but observers seemed to consider him a “crank and a fraud” more than someone who was insane. A court commission did find him insane, though, and recommended he be sent to an asylum. Remshaw was sent to the Insane Department of the State Prison at Auburn.

Gray died November 29, 1886 from causes attributed to his decline in health following the shooting.

*Quoted from an article from the Journal of Psychological Medicine and Mental Pathology.

Thoughts on Religion

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Causes of Insanity Included Religious Excitement

Discovering the reasons for insanity proved difficult for early alienists. For many years, these mental health experts attributed the origins of insanity to what modern medicine would call laughable causes: excessive novel-reading, masturbation, smoking, religion and so on. Eventually, a few medical men began to question these sorts of factors as true causes of mental issues.

Dr. John Gray, superintendent of the State Lunatic Asylum in Utica, New York, wrote in 1885 that, “Religion, strange to say, is sometimes set down as a cause of insanity . . . . To some it means that a person is insane on the subject of religion; to others that the insanity was caused by religion.”

Dr. John Gray

Gray recognized that the idea of “Religious Insanity” actually meant that religion caused insanity to many people. His belief, though, was that: “What people talk about when they become insane, has rarely anything to do with the real cause of the disease.” Gray gave a couple of examples concerning his theory, one being the case of a severely overworked minister who finally broke down and began raving that he was Zerubbabel and had been appointed by God to preach “to the spirits in prison” and that he had descended into hell to preach the gospel of salvation and redemption.

“This was not Religious Insanity,” said Gray, “but insanity from exhaustion, religion having nothing to do with it except to give tone and character to his delusions.” Gray found that many people who appeared insane due to exhaustion or broken health could often recover when given rest and proper medical treatment.

State Lunatic Asylum, Utica, New York, courtesy National Library of Medicine

His point of view was a refreshing counterpoint to others in his field who would have labeled a patient like this insane and perhaps never expected a recovery.

Healing, Hell, and the History of American Insane Asylums

The History of Insane Asylums

Nostalgia and Insanity

Mental Illness and the Civil War

Medical and Mental

Work and Money

Other Ways to Help the Insane

Ways to Treat the Insane

Plight of the Attendant

Plight of the Sane

Asylum Superintendent’s Job Included Danger

Thoughts on Religion